Accepted: 27 January 2018

DOI: 10.1111/pan.13350

EDUCATIONAL REVIEW

Anesthesia of thoracic surgery in children

Axel Semmelmann | Heike Kaltofen | Torsten Loop

Department of Anesthesiology and

Intensive Care Medicine, University Medical
Center, Freiburg, Germany
Correspondence
Dr Axel Semmelmann, Department of
Anesthesiology and Intensive Care Medicine,
University Medical Center Freiburg, Freiburg,
Germany.
Email: axel.semmelmann@uniklinik-freiburg.
de
Section Editor: Mark Thomas
Summary
Providing anesthesia in children with thoracic disease is a challenging task. The
effects of the underlying disease, the surgical interventions, and preexisting condi-
tion of the patient need to be considered when planning perioperative care. The
perioperative care for children undergoing thoracic surgery requires specific tech-
niques adapted to the pediatric physiology and anatomy. This review is focused on
anesthetic strategies for thoracic surgery with an emphasis on perioperative
analgesia including neuraxial techniques.

KEYWORDS
airway, child, device, regional, respiration, technique

1 | INTRODUCTION 2 | PEDIATRIC AIRWAY AND

Performing anesthesia in pediatric thoracic surgery may be a chal-
lenge. Varying stages of the pediatric development require a thor-
ough understanding of the different physiologic states and the
anesthetic management for interventions of lung, airway, or other
thoracic organs between neck and abdomen, which compromise the
cardiorespiratory system. Surgical correction of congenital defects is
performed in the neonatal period if symptomatic or secondary, if
complications occur. Neoplastic or other acquired lesions manifest at
any stage of life. Infectious disease as empyema is a common cause
necessitating thoracic surgery in preschool children. Correction of
chest deformities is mainly performed in adolescents (Table 1). With
the implementation and advances of the video-assisted thoraco-
scopic surgery, surgical procedures will be performed with increasing
frequency in children. Factors to be considered when planning and
providing anesthesia for thoracic surgery include type and site of
lesion, surgical approach, and comorbidities. Specific aspects of the
unique pediatric physiology and anatomy influence anesthetic man-
agement. Adult principles cannot be routinely applied.
This review delineates the anesthetic management of pediatric
patients presenting for thoracic surgery. Cardiac surgery is beyond
the scope of this review. Airway and respiratory physiology, periop-
erative analgesia focused on regional anesthesia and management of
specific surgical procedures are to be reviewed (see also the Audio
file S1).
RESPIRATORY PHYSIOLOGY
Specific considerations of the upper airway anatomy influencing
general airway management have been discussed previously.1
Higher airway resistance and airflow limitations exacerbated by
airway manipulation or soiling, a tendency toward lung collapse
based on anatomy, physiology, and physics of the pediatric lung in
combination with proportionally higher oxygen consumption render
young children prone to respiratory complications. In the lateral
decubitus position, the highly compliant rib cage is unable to
avoid compression of the dependent lung from external padding
and positioning in addition to compression by mediastinal and
abdominal contents. This results in a lower functional residual
capacity close to or below residual volume, making airway closure
likely to occur in the dependent lung especially in young infants
and newborn. Adverse effects become more obvious after the
nondependent lung with its better ventilation/perfusion match is
collapsed.2 In proportion to the body size, the lower hydrostatic
gradient cannot ameliorate the ventilation/perfusion-mismatch as
in older children and adults. These problems are aggravated in
premature infants or in patients with preexisting disseminated lung
disease.2,3
As a conclusion, tendency toward shunt and hypoxemia is more
pronounced when one-lung ventilation is performed in the depen-
dent lung in very young patients contrary to older children and

Pediatric Anesthesia. 2018;1–6. wileyonlinelibrary.com/journal/pan © 2018 John Wiley & Sons Ltd | 1
2 | SEMMELMANN ET AL.

T A B L E 1 Thoracic disease in children necessitating surgical (DLT) or the Univentâ tube, is restricted to older children (Figure 1).
intervention Bronchial blockers or endobronchial intubation with a standard endotra-
Etiology Examples cheal tube can be applied in nearly every age group. To avoid malposi-
Congenital Congenital diaphragmatic hernia tioning, fiber-optic bronchoscopic guidance and control of correct
Tracheo-esophageal fistula positioning is recommended for every technique, as the margin of error

Esophageal atresia
correlates to the child`s size. The need for airway manipulations as suc-
tioning or applying continuous positive airway pressure mandates the
Congenital lobar emphysema
use of a bronchial blocker with an integrated lumen or a double-lumen
Congenital cystic adenomatoid malformation
tube, as they provide selective access to both lungs.
Pulmonary sequestrations
Neoplastic Lymphoma (lymphoblastic lymphoma,
Hodgkin lymphoma)
Teratoma 4 | RELEVANCE OF PERIOPERATIVE
Neuroblastoma REGIONAL ANALGESIA
Thymoma
Infectious Empyema thoracis Thoracic epidural anesthesia contributes to reduced perioperative

Consolidated pneumonia/abscess
morbidity especially in adults with limited pulmonary function by
reducing respiratory and cardiac complications and the incidence of
Acquired Thoracic trauma
acute and chronic pain.7,8 Increasing evidence supports the imple-
Inhaled foreign body
mentation of optimized analgesic regimens including regional analge-
Tracheal stenosis
sia into the perioperative management as the effects of
Chest deformities Pectus excavatum/carinatum
perioperative pain and associated deleterious sequelae became evi-
dent also in children.9,10 Regional anesthesia has been shown to
adults.4,5 The lateral decubitus position would favor the good lung in
reduce pain scores, the incidence of nausea and vomiting, pulmonary
the nondependent position.
complications, and markers of endocrine stress response.10 In
younger children with immature neuronal structures, adequate regio-
nal anesthesia can avoid exposure to potential neurotoxic anesthet-
3 | AIRWAY MANAGEMENT FOR ONE-
ics and reduce hypersensitivity resulting from inadequate
LUNG VENTILATION
analgesia.11 Regional anesthesia includes intercostal blockade, par-
avertebral, and epidural anesthesia (Table 3). In patients undergoing
Thoracic surgical access can be achieved by thoracotomy or video-
surgery for chest deformities, epidural and paravertebral analgesia
assisted thoracoscopy. Establishing one-lung ventilation is desirable to
reduce pain levels and length of hospital stays after pectus excava-
minimize mechanical lung injury by retractors or surgical instruments, to
tum or funnel chest repair. Within recent years, there is growing evi-
optimize visualization and to protect against soiling or air leakage. Gen-
dence for the feasibility and beneficial effects of epidural and
eral principles of lung isolation apply for both adult and pediatric
paravertebral analgesia even in very young pediatric patients under-
patients. A detailed review of one-lung management in children has
going thoracotomy and thoracoscopy.12 Though neuraxial techniques
been published recently.6 The small size of the pediatric airway is the
improve effective analgesia, the impact on morbidity and mortality,
main factor guiding airway management. Therefore, the use of rather
as shown for adults, is less conclusive in pediatric patients, possibly
bulky devices for one-lung ventilation (Table 2), as double-lumen tubes
explained by a more preserved lung function, the higher primary fail-
T A B L E 2 Age adapted selection of airway management for one- ure rate, the small numbers of well controlled studies and the limited
lung ventilation size and heterogeneous character of the existing studies.
Bronchial Flex. broncho-
ETT blocker scope
(mm inner DLT (French)/ (mm outer
Age (years) diameter) (French) (position) diameter) 5 | PRACTICAL ASPECTS OF NEURAXIAL
Newborn 3-3.5 - 3/extraluminal 1.8 TECHNIQUES
<1 3.5-4 - 5/extraluminal 1.8
1-2 4-4.5 - 5/extraluminal 1.8 In young children, epidural and paravertebral analgesia is inserted after
2-4 4.5-5 - 5/extraluminal 1.8 induction of general anesthesia in contrast to the practice in coopera-
4-6 5-5.5 - 5/intraluminal 1.8 tive adolescents and adults.13 Among anesthetists, there is much hesi-
6-8 5.5-6.5 26 5/intraluminal 1.8 tance to perform neuraxial anesthesia in a sedated patient.
8-10 6.5 26-28 5/intraluminal 2.8 Nevertheless, there is evidence that thoracic epidural analgesia in
10-12 6.5-7 28-32 7/intraluminal 2.8 pediatrics is equally safe when inserted under general anesthesia.14
12-14 7 32-35 7/intraluminal 2.8 Ultrasonography is used increasingly to facilitate epidural and
SEMMELMANN ET AL.
F I G U R E 1 Airway management:
Univentâ-tube (U) (3.5 mm ID) and 26
French DLT (DLT) in relation to a standard
ETT (S) (6.5 mm ID). 5 French Fujiâ (F) and
Arndtâ (A)-bronchial blockers next to a
3.5 mm ID ETT
T A B L E 3 Recommendations for regional anesthesia in thoracic surgery
Type Needle/catheter (Gauge) Drug
Epidural <30 kg: 20/25; 19/23 ropivacaine 0.2% + sufentanil
>30 kg: 18/21 0.5 lg/mL
Paravertebral <30 kg: 19/23 ropivacaine 0.2%
>30 kg: 18/21
Intercostal 22 ropivacaine 0.5% + epinephrine
5 lg/mL
paravertebral anesthesia. Significant differences regarding the pedi-
atric neuraxial anatomy exist, that is, a very short skin-epidural dis-
tance, a narrow epidural space and a softer ligamentum flavum, which
increase the technical challenge and result in a small margin of
15
safety. Advancing the catheter via the caudal or lumbar route was
thought to avoid direct trauma at the thoracic level in children under
the age of 1 year. An increased incidence of infection and malposition
and a higher traumatizing effect caused by this method has been dis-
cussed. Catheter-related complications seem to be higher than in
adults, especially in neonates and small infants, though the overall rate
of severe damage seems to be reasonably low confirming feasibility
and safety. Thoracic paravertebral analgesia seems to be associated
with a safer profile compared to thoracic epidural analgesia based on
the distance between the paravertebral space and the spinal cord.
Within recent years, ultrasound guidance results in increased efficacy
in placement. Single shot and continuous paravertebral analgesia are
common.12 In general, neuraxial anesthesia may provide a safe, effec-
tive, and improved analgesia compared to systemic opioid analgesia.
The choice of technique depends on the type of surgery, patient fac-
tors, and the experience of the anesthesiologist. The existence of spo-
radic reports on spinal damage, the higher technical challenge, and
less pronounced effects of neuraxial anesthesia on pediatric outcome
require a thorough assessment of the individual risk and benefit in
every single case. Alternative techniques and the use of ultrasound
guidance should be considered to increase patient safety.
6 | PHARMACOLOGY OF NEURAXIAL
DRUGS IN CHILDREN
Pharmacodynamics and -kinetics of local anesthetics differ in very
young pediatric patients compared to adults resulting in an increased
| 3
Initial bolus Continuous application
<3 month 0.2 mg/kg <3 month: 0.1-0.2 mL/kg/h
>3 month: 0.3 mL/kg >3 month: 0.1-0.2 mL/kg/h
Total 0.5 mL/kg (3 separate sites) 0.2 mL/kg/h
Total 0.5 mL/kg (6 segments) (single shot)
risk of accumulation and toxicity.16 Though the larger volume of dis-
tribution limits peak plasma levels after a single dose, the risk of
accumulation is increased after continuous application.16 Immature
organ function and metabolism need to be considered in infants
younger than 3 months. The blood-brain barrier is more permeable.
Ropivacaine seems to be relatively safe even in young children less
than 3 months of age and can be considered the local anesthetic of
choice with a maximal dose of 0.2 mg/kg/h for continuous applica-
tion16 (Table 3). Accumulation of ropivacaine 0.2% seems to be mini-
mal for children >3 months even when continuously administered.
Levobupivacaine is associated with less toxicity than the R-isomer.
The epidural application of opioids results in improved analgesia also
in children (Table 3). Epidural sufentanil offers favorable pharmacoki-
netic and -dynamic properties. For paravertebral analgesia, doses are
often higher compared to epidural analgesia. As an alternative, the
administration of intrathecal morphine provides potent analgesia for
12-24 hours.12
7 | SPECIFIC LESIONS AND PROCEDURES
7.1 | Surgical approach: video-assisted thoracic
surgery (VATS) versus thoracotomy
Thoracoscopic procedures are associated with reduced muscu-
loskeletal trauma, less pain resulting in enhanced recovery and
optimized magnified visualization.17 Novel surgical instruments
facilitate VATS in small and newborn children. VATS is possible
even in the repair of esophageal atresia with tracheal fistula or a
congenital diaphragmatic hernia, reserving thoracotomy for compli-
cated and extensive disease not accessible by VATS. Establishing
one-lung ventilation is desirable for both approaches. During tho-
racotomy, retraction of the inflated lung can improve visualization
4 |
in emergency or lack of lung separation, whereas this is usually
impossible in thoracoscopic procedures without CO2-insufflation.
CO2-insufflation into the hemithorax is used to improve visualiza-
tion, either as single means or in combination with specific lung
isolation. Low gas flow and an insufflation pressure between 4-
6 mbar seem to be sufficient.17 Care must be taken to avoid or
limit side effects as hypothermia, hypercarbia, and excessive
increases of the intrathoracic pressure lead to cardiopulmonary
compromise. Regional anesthesia (ie, thoracic epidural or paraver-
tebral anesthesia, intercostal blockade) provide effective periop-
erative analgesia, depending on the extent of the surgical
intervention.
8 | EMPYEMA
Pneumonia in children may be complicated in 5-10% by parapneu-
monic empyema with an even increasing incidence.18 Pulmonary
gas exchange in terms of an accompanying pneumonia may be
insufficient, especially during one-lung ventilation. Lack of clinical
improvement after antibiotic therapy and chest drainage should
prompt a surgical consultation. There is an emerging role for pri-
mary thoracoscopy in empyema. Thoracotomy is reserved for spe-
cial cases in persistent sepsis or complicated empyema.19 Lung
isolation is mandatory as soiling of the less affected side could lead
to respiratory impairment after positioning or surgical manipulation.
Primary bronchoscopy with a supraglottic airway device before sur-
gery can be considered in the presence of massive secretions
potentially complicating one-lung ventilation. Any change in position
can dislodge secretions and result in respiratory deterioration. Ade-
quate venous access for goal-directed fluid and hemodynamic man-
agement is mandatory to restore perfusion as indicated by
hemodynamic or biochemical parameters, capillary refill, or urine
20
output. Dependent on the comorbidity, the extent of the opera-
tion and the presence of acute septicemia, regional anesthesia or
further monitoring should be established as indicated. For surgical
interventions of limited extent, intercostal blockade may induce
effective analgesia. Thoracic epidural anesthesia has been shown to
be safe and improves analgesia in children undergoing thoracotomy
and decortication. As the parietal pleura is the anterior border of
the paravertebral space, complete decortication and the risk of
infection are contraindications for thoracic paravertebral analgesia.
Postoperative admission to a high dependency unit is necessary to
provide respiratory care.
9 | TRACHEO-ESOPHAGEAL FISTULA (TEF)
TEF is found in 1 of 3.000 neonates. Fifty percent of the children
are born with other abnormalities (ie, VACTERL), mainly cardiac
(~50%). Problems may arise from concomitant cardiac disease, pre-
maturity including low birth weight (especially <2 kg) and res-
piratory insufficiency, all of which often need preoperative
SEMMELMANN ET AL.
optimization. Airway management is influenced by the size and
site of the fistula, serving as a conduit between stomach and air-
ways. For many years, the standard textbook approach has been
to avoid mask ventilation and aim for early intubation with pre-
served spontaneous ventilation minimizing air leakage and gastric
distention until identification and subsequent closure of the fistula.
Management has changed over the years. In patients with small
fistulae without respiratory compromise, controlled ventilation
seems to be relatively safe. Risk factors include large, pericarinal
fistulae and presence of respiratory distress.21 In children undergo-
ing thoracotomy and presenting with respiratory distress, sponta-
neous ventilation is not always sufficient. Endotracheal intubation
distal to the fistula should be performed if possible. Lung separa-
tion with a balloon tipped catheter may be a strategy to avoid
gastric insufflation.
Intraoperative problems are endotracheal tube dislocation caused
by surgical manipulation or positioning with resulting gastric disten-
tion and severe respiratory complications. The availability of a flexi-
ble bronchoscope is mandatory to correct potential life threatening
dislocation of the endotracheal tube or respective airway device.
Transcutaneous CO2-monitoring is helpful. If performing thoraco-
scopic repair, lung collapse can be hastened by CO2-insufflation.
One-lung ventilation may result in increased pulmonary vascular
resistance, so patients with cardiac disease and intracardiac shunts
can be compromised.21 CO2-absorption, hypothermia, and acidosis
can aggravate this. In addition to standard monitoring, invasive arte-
rial and central venous access should be sought for patients with
cardiorespiratory impairment. Epidural, paravertebral, and caudal
anesthesia have been proven beneficial. Postoperative intensive care
is necessary for all patients. The need for ventilation is determined
by the extent of the operation and possible complications, adequate
pain management, and the presence of cardiac or pulmonary comor-
bidity.21
10 | CONGENITAL DIAPHRAGMATIC
HERNIA (CDH)
Abdominal viscera herniating through a diaphragmatic defect into
the hemithorax with subsequent lung hypoplasia are hallmarks of
this lesion. Pulmonary hypertension, persistent patent ductus arterio-
sus, or foramen ovale may result. Associated congenital lesions
include cardiac, central nervous, and gastrointestinal disorders. The
size of the hernia, respiratory compromise, and the presence of car-
diovascular disease determine morbidity and mortality.22 As prob-
lems arise directly after birth, delivery and primary care should be
planned in a tertiary hospital.
Therapeutic aims are the pre- and perioperative stabilization with
a focus on avoiding aggressive ventilation. Most neonates with CDH
require mechanical ventilation, including high frequency oscillatory
ventilation or even extracorporeal circulation support in severe
cases. Lung compression by gastric contents may be aggravated by
vigorous attempts of mask ventilation, gastric distention further
SEMMELMANN ET AL.
compressing lung parenchyma. Reduced alveolar surface, atelectasis
and shunting, pulmonary hypertension, and a persistent right to left
shunt promote hypoxemia. Early endotracheal intubation is indicated
and a nasogastric tube should be inserted. Aggressive ventilation
causing baro- and volutrauma further damage the lung resulting in
long-term damage. Protective ventilation includes limited peak pres-
sures and permissive hypercapnia. High frequency oscillatory ventila-
tion is frequently used in compromised patients, extracorporeal
membrane oxygenation can be considered in refractory cases. Pul-
monary hypertension is targeted by correction of hypoxemia and aci-
dosis. Pharmacologic therapy includes inhaled nitric oxide,
22
phosphodiesterase inhibitors, prostaglandins and cyclins. A right
(preductal) arterial cannula is inserted. Pre- and postductal oxygen
saturations are monitored indicating changes in right to left shunt.
Vasoactive therapy is often required. Surgical therapy includes repo-
sitioning of the displaced viscera and closure of the diaphragmatic
defect by the abdominal approach. VATS or thoracotomy approach
is used less often, so lung isolation is usually not required to facili-
tate surgical exposure. Aggressive ventilation resulting in RDS and
pneumothorax should be avoided in the perioperative period.
Abdominal closure can result in hemodynamic and respiratory com-
plications. Postoperative intensive care including ventilation is neces-
sary, as respiratory impairment often persists owing to lung
hypoplasia. Survival is influenced by concomitant defects, the pres-
ence of organ failure, and degree of recovery. Prenatal, intrauterine
interventions are increasingly used with different therapeutic
approaches.
11 | CONCLUSION
Thoracic anesthesia in children may be a challenging task. In order to
establish a safe and adequate perioperative management, the anes-
thesiologist needs to incorporate the patient’s age and preoperative
condition, the pathophysiology of the underlying disease and impli-
cations of the planned intervention. A detailed concept for every
patient should be tailored including airway management for OLV and
perioperative analgesia as well as the perioperative disposition. Sim-
ply transferring adult management principles is often not feasible. A
clear understanding of the interdependent pathologies and develop-
ing changes enables the clinician to deal with possible complications.
Further clinical studies will be needed to determine the impact of
protective ventilation and the benefit of neuraxial anesthesia in chil-
dren.
CONFLICT OF INTEREST
The authors report no conflict of interest.
REFLECTIVE QUESTIONS
After reading this article, the reader should be able to answer the
following questions.
| 5
What are the main differences between adult and pediatric
patients presenting for thoracic surgery influencing the anesthetic
management?
Explain the perioperative problems encountered in children pre-
senting with empyema?
Which regional anesthetic techniques can be performed to pro-
vide adequate pain relief for thoracotomies and thoracoscopic sur-
gery?
Discuss the technical options and pharmacologic aspects of neu-
raxial anesthesia in especially young children presenting for thoracic
surgery.
ORCID
Axel Semmelmann http://orcid.org/0000-0002-8811-5755
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